Laserfiche WebLink
San Joaquin County Environmental Health Department Unit IV Well Permit Application Supplemental <br />L4 11 01;7l 17117. <br />PERMIT SR # <br />I hereby affirm that I am licensed under the provisions of Chapter 9 (commencing with Section 7000) of <br />Division 3 of the Business and Professions Code and my license is in full force and effect. <br />License #: J Exp Date:l <br />Date: o Contractor: <br />VJ <br />Signature: _ Title: <br />Print Name: C VA SIy <br />WORKER'S COMPENSATION DECLARATION <br />I hereby affirm under penalty of perjury one of the following declarations: (check one) <br />I have and will maintain a certificate of consent to self -insure for workers' compensation, as <br />provided for by section 3700 of the labor Code, for the performance of the work for which this <br />permit is issued. <br />I have and will maintain workers' compensation insurance, as required by Section 3700 of the <br />Labor Code, for the performance of the work for which this permit is issued. My workers' <br />compensation ginsurance carrier and policy numbers are: <br />Carrier: `'� `�bV1 Policy Number: <br />I certify that in the performance of the work for which this permit is issued, I shall not employ any <br />person in any manner so as to become subject to the workers' compensation law of California, and <br />agree that if I should become subject to workers' compensation provisions of Section 3700 of the <br />Labor Code, I shall forthwith comply with those provisions. <br />Exp. Date: �i 1 1iZ� Signature: <br />Print Name: NO µ*G,/ i -)`q <br />WARNING: FAILURE TO SECURE WORKERS' COMPENSATION COVERAGE IS UNLAWFUL, AND SHALL SUBJECT AN EMPLOYER TO <br />CRIMINAL PENALTIES AND CIVIL FINES UP TO $100,000, IN ADDITION TO THE COST OF COMPENSATION, INTEREST, <br />ATTORNEY'S FEES, AND DAMAGES AS PROVIDED FOR IN SECTION 3706 OF THE LABOR CODE. <br />ATION FOR OTHER THAN C-57 SIGNING PERMIT APPLICATION <br />I, (signature of C-57 licensed authorized representative), <br />hereby authorize (print name) , to <br />sign this San Joaquin county Well Permit Application on my behalf. I understand this authorization is valid <br />for one year and is limited to the work plan dated on the front page of this application. <br />81291021MI <br />EHD 29-01 1115107 WELL PERMIT APP <br />